Provider Demographics
NPI:1730430703
Name:LAKESHORE PREMIUM HEALTHCARE, INC
Entity type:Organization
Organization Name:LAKESHORE PREMIUM HEALTHCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-584-2059
Mailing Address - Street 1:3000 N HALSTED ST
Mailing Address - Street 2:SUITE 609
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5188
Mailing Address - Country:US
Mailing Address - Phone:949-584-2059
Mailing Address - Fax:949-679-9174
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 609
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:949-584-2059
Practice Address - Fax:949-679-9174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1312632084P0800X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty